Study guide
1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI
ABIM Internal Medicine Exam
Track your progress as you read
Finished sections get a check mark.
1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI
Key Takeaways Explain This Topic AI
Antithrombotic therapy in cardiovascular disease is its own named blueprint subsection, distinct from ischemic heart disease.
Post-MI mortality benefit is driven by antiplatelet therapy, high-intensity statin, beta-blocker and renin-angiotensin blockade, with mineralocorticoid antagonism added for reduced ejection fraction.
Ventricular septal rupture produces an oxygen saturation step-up from right atrium to right ventricle; acute mitral regurgitation from papillary muscle rupture does not.
Free wall rupture presents as sudden pulseless electrical activity with tamponade physiology and is most common in late-presenting, non-reperfused infarcts.
Mechanical complications cluster in the first three to five days and are far more likely when reperfusion was delayed or omitted.
Last updated: August 2026
- 1. Antithrombotic Therapy: DAPT & Anticoagulation
- Dual Antiplatelet Therapy (DAPT)
Aspirin: 162-325 mg non-enteric chewable loading dose immediately, followed by 81 mg daily indefinitely.
P2Y12 Receptor Inhibitor Selection:
Ticagrelor (Brilinta): 180 mg loading dose, then 90 mg PO BID. Reversible, direct-acting P2Y12 inhibitor. Superior to Clopidogrel (PLATO trial). Side effects: dyspnea (self-limiting, related to adenosine reuptake inhibition), ventricular pauses, hyperuricemia.
Prasugrel (Effient): 60 mg loading dose, then 10 mg PO daily (5 mg daily if weight <60 kg). Potent irreversible thienopyridine. Superior to Clopidogrel (TRITON-TIMI 38). Strictly contraindicated in patients with a history of stroke or TIA (excess fatal ICH); not recommended in patients aged >=75 years unless high risk (DM or prior MI).
Clopidogrel (Plavix): 300-600 mg loading dose, then 75 mg PO daily. Indicated when Ticagrelor/Prasugrel are contraindicated, in patients with high bleeding risk, or when triple antithrombotic therapy is required.
DAPT Duration:
Standard ACS: 12 months minimum regardless of bare-metal stent (BMS), drug-eluting stent (DES), or medical therapy alone.
High Bleeding Risk (ARC-HBR): De-escalation or shortening to 1-6 months of DAPT followed by P2Y12 monotherapy (e.g., Ticagrelor or Clopidogrel) or Aspirin monotherapy.
Prolonged DAPT (>12 months): For patients with high ischemic risk (prior stent thrombosis, bifurcation stents, multivessel disease, DM) and low bleeding risk (DAPT score >=2), continuation of DAPT (e.g., Aspirin + Ticagrelor 60 mg BID via PEGASUS-TIMI 54) reduces recurrent ischemic events.
Anticoagulation Regimens
Unfractionated Heparin (UFH): IV bolus 60 units/kg (max 4,000 units), then 12 units/kg/h (max 1,000 units/h) titrated to target aPTT 50-70 seconds. Anticoagulant of choice for primary PCI (target ACT 250-300 seconds without GP IIb/IIIa inhibitor).
Low-Molecular-Weight Heparin (Enoxaparin): 1 mg/kg SC q12h (1 mg/kg SC q24h if CrCl <30 mL/min). Preferred over UFH in medically managed NSTE-ACS (SYNERGY trial).
Bivalirudin: Direct thrombin inhibitor; alternative in PCI, particularly for patients with heparin-induced thrombocytopenia (HIT) or high bleeding risk.
Fondaparinux: 2.5 mg SC daily (factor Xa inhibitor); lowest bleeding risk in NSTE-ACS. Must be supplemented with UFH bolus during PCI to prevent catheter-associated guide thrombosis.
2. Post-MI Guideline-Directed Secondary Prevention
Long-term medical therapy after MI significantly reduces mortality, recurrent reinfarction, and progressive ventricular remodeling:
High-Intensity Statin Therapy: Atorvastatin 80 mg daily or Rosuvastatin 40 mg daily started immediately regardless of baseline LDL-C. Goal is >=50% reduction in LDL-C and LDL-C <55 mg/dL (<1.4 mmol/L). If LDL-C remains >=70 mg/dL (or >=55 mg/dL per ACC/ESC) on maximally tolerated statin, add Ezetimibe 10 mg daily; add PCSK9 inhibitor if still above goal.
Beta-Blockers (Carvedilol, Metoprolol Succinate, Bisoprolol): Initiate within 24 hours in hemodynamically stable patients (no signs of acute HF, low-output state, bradycardia, or PR >240 ms). Continue for at least 3 years in patients with preserved EF, and indefinitely if LVEF <=40%.
ACE Inhibitor or ARB: Initiate within 24 hours in all patients with anterior infarction, LVEF <=40%, clinical heart failure, hypertension, or diabetes mellitus. Continue indefinitely.
Mineralocorticoid Receptor Antagonist (MRA - Eplerenone 25-50 mg or Spironolactone 25-50 mg): Class I indication for post-MI patients already on therapeutic doses of an ACEi/ARB and beta-blocker who have LVEF <=40% AND either clinical heart failure symptoms or diabetes mellitus (EPHESUS trial). Criteria: Serum K+ <=5.0 mEq/L and eGFR >=30 mL/min/1.73m2 (serum creatinine <=2.5 mg/dL in men, <=2.0 mg/dL in women).
Anti-anginal / Lifestyle: Sublingual nitroglycerin 0.4 mg PRN, cardiac rehabilitation referral, smoking cessation, annual influenza and pneumococcal vaccination.
3. Mechanical Complications of Myocardial Infarction
Mechanical complications typically develop 3 to 7 days post-MI (range: 1-14 days) due to coagulation necrosis, neutrophilic infiltration, and collagen lysis weakening the necrotic myocardial tissue. They are more frequent after transmural STEMI with delayed or absent reperfusion.
Complication Culprit Artery / Anatomy Clinical Presentation Physical Exam Findings Hemodynamics / Diagnostics Definitive Management
Free Wall Rupture LAD (anterior) or RCA (lateral/inferior) Sudden catastrophic hemodynamic collapse, syncope, PEA arrest Distant heart sounds, severe JVD, hypotension ( Beck's Triad ), pulsus paradoxus Bedside Echo: Hemopericardium, pericardial tamponade with RV diastolic collapse Emergency pericardiocentesis + immediate emergent surgical repair / pericardial patch
Ventricular Septal Rupture (VSR) LAD (apical VSR) or RCA (basal posterior VSR) Biventricular failure, sudden cardiogenic shock, hypotension Harsh, loud holosystolic murmur at lower left sternal border with a palpable thrill Swan-Ganz Catheter: Oxygen saturation step-up >=10% from Right Atrium to Right Ventricle Afterload reduction (IV nitroprusside), IABP / Impella mechanical support, urgent surgical repair
Papillary Muscle Rupture RCA / PDA (posteromedial muscle: single blood supply) >> LAD/LCx (anterolateral: dual supply) Sudden severe dyspnea, flash pulmonary edema, cardiogenic shock Soft or harsh apical holosystolic murmur radiating to axilla (may be soft/inaudible if LA-LV pressures equalize) Echo: Severe eccentric acute MR, flail leaflet. Swan-Ganz: Giant 'v' waves on PCWP tracing Urgent afterload reduction, IABP, emergency surgical mitral valve repair or replacement (MVR)
Board Exam Contrast — VSR vs. Papillary Muscle Rupture:
Both present 3-7 days post-MI with severe hemodynamic deterioration and a new holosystolic murmur.
Ventricular Septal Rupture: Murmur heard at LLSB, associated with a palpable thrill , and causes a step-up in oxygen saturation in the right ventricle on pulmonary artery catheterization.
Papillary Muscle Rupture: Murmur heard at the apex radiating to the axilla, no thrill , normal RV O2 saturation, but demonstrates giant 'v' waves on the pulmonary capillary wedge pressure (PCWP) tracing.